Health and Social Care Bill

Baroness Barker Excerpts

Tuesday 11th October 2011 Lords Chamber

[Baroness Barker]

My Lords, I have never been the 73rd speaker in a debate in your Lordships' House before, but that is because I have never spoken about reform of the House of Lords or hunting. I have watched people who have spoken at spot number 73, and at this time of night it is not about great oratory; it is about making four or five key points that point up major issues of the Bill. That is what I am going to do.

Several hours ago, the noble Earl, Lord Howe, set out his eloquent introduction to the reasoning behind the Bill. He talked, as did the noble Baroness, Lady Thornton, about the antecedents to the Bill—not many of the Bills debated in this House during the time of the Labour Government, as she said. One of the key antecedents to this Bill was the Wanless report of 2004, a piece of work remarkable for its depth and detail. In essence it said three things. The first was that whatever the level of resources we give to the NHS, we will never ever be able to meet demand fully. It went on to say that the long-term viability of an NHS that is free at the point of need depends on two things in particular: the extent to which the public are engaged in protecting their own health and the extent to which clinicians are involved in decision-making and innovation.

The Wanless report informed much of the work of the noble Lord, Lord Darzi—the work on the NHS constitution, for example. That, in turn, has formed some of the building blocks of this legislation. In so far as it does, I welcome some of it. Like other noble Lords who have spoken from these Benches, I welcome some of the things in the Bill. Health and well-being boards and the integration of public health and local government are long overdue. Just as Derek Wanless said all those years ago, there are very many determinants of health, the answers to which lie outwith the scope of the NHS, and they always will. That is an important achievement which is in this Bill as the result of work by some of my Liberal Democrat colleagues.

However, there are a number of issues on which I and my colleagues, notwithstanding the work of some of my colleagues down the other end, remain to be convinced. Much has already been said on the Secretary of State’s duties and accountability. There is a key question which I think every person in the land wishes to be able to answer. Who is ultimately responsible for my local health service, and if it is poor, who is responsible for sorting it out? Some people may be forgiven for thinking that at the moment there is an easy answer to that question. Very often there is not an answer at all, and very often if there is an answer, the answer is “the Secretary of State”. That, I am afraid, is not an acceptable way to go forward for much of our health service.

I listened very carefully to the comments of the noble Lord, Lord Owen, and I agree with him: it is inconceivable that in extremis the Secretary of State could not take emergency and urgent powers to order the NHS to cope with something such as a pandemic. The truth is that most of the time the NHS is not working in extremis—it is working on day-to-day health. The issue identified by my noble friend Lord Marks in the Bill is the duty of the Secretary of State to promote autonomy. Those two things are incompatible. We need to assess the duty of the Secretary of State, as the noble Earl, Lord Howe, said this morning, as part of a long chain of responsibility, from the NHS Commissioning Board, through Monitor, to clinical commissioning groups.

I want to ask the Minister a key question. In what circumstances will departmental Ministers be obliged to answer detailed questions in Parliament on the performance of NHS commissioners and providers, and what will be the nature of any direct lines of accountability between Parliament, the NHS Commissioning Board and Monitor? The accountability of the NHS Commissioning Board is a matter of great concern to me. The idea of an independent board was one which surfaced as Conservative policy in, I think, 2007. It was very much favoured by a number of the health think tanks at the time and then disappeared without trace until it re-emerged after the election. Now it is in this Bill, but there are a great many questions of detail which still need to be answered. Its accountability to the public, given that it has extensive powers, needs to come under much greater scrutiny than is currently planned. I should like to know whether the Commissioning Board will be subject to the same standards of accountability as clinical commissioning groups. The Commissioning Board will also be responsible for holding commissioning groups to account for their performance. It will do so with reference to quality outcomes, commissioning guidance and the commissioning outcomes framework. Can the Government say how the board itself will be held to account for the quality of its own commissioning? By whom will it be held to account?

There has been an awful lot of talk today about competition. Much of it, I think, has been slightly off the mark. I think it is now true that any qualifying provider will be limited to those areas where there is a national or local tariff, ensuring that competition is based on quality, not on price. I am sorry that a number of noble Lords are not present. I would say to the noble Baroness, Lady Jay of Paddington, who quoted the example in Surrey, and to the noble Baroness, Lady Royall, that the examples they gave of services being tendered out are happening under the current legislation and are being done on price alone. That is unacceptable. In the course of our deliberations on this Bill, I think we should go back and take out some of the stuff that was introduced by previous Labour Ministers which favoured private sector providers. That was absolutely unacceptable. If we have to have competition, I want to see it on quality of outcomes. However, I say to noble Lords that it is not the issue of competition law but the issue of procurement law that we really need to scrutinise in great detail. That is a very technical matter that I do not propose to go into at this time of night. For those of us who have worked in social care, we know that it is the effects of procurement law that can have the more far-reaching consequences.

The reason for having this Bill is to deal with very significant challenges to the health service, one of which is dementia. I am not going to remind noble Lords of the scale of the problem of dementia. In 30 years’ time 1.5 million families will be dealing with it. It is therefore important that, throughout this Bill, carers in particular have a far greater role in the design and commissioning of services than now. I will wish to see that strengthened.

By all means, we should debate the private patient income cap. We did so in this House in November 2009, at the instigation of a noble Baroness on the Cross Benches. The NHS has raised money from private patients since approximately 1948. The issue that is more important than the cap is the requirement on trusts to show how and precisely why they have chosen to accept private patients and how it will benefit their NHS patients. It can—we know that it is possible to develop a lot of research through private income, which ultimately has a benefit for NHS patients.

I want to finish on the question of the two amendments before us. The amendment tabled by the noble Lord, Lord Rea, is clear in its motivation, its intention and its effect. I do not think the arguments for it were particularly strong and I say to those Members on the Labour Benches who have been critical of the NHS for anticipating this legislation that I do not recall PCTs hanging around in 2006 for the passage of that legislation. In 2008, the Government went ahead with appointing the chair and the chief executive of the CQC before this House had finished debating the legislation on setting up that body.

To the noble Lord, Lord Owen, I simply say that I want to defend the NHS and am as passionate about that as any of the other speakers today. This Bill deserves the most detailed scrutiny that this House can give it. The scope and detail of today’s debate have shown the standard of scrutiny that it may receive. I genuinely do not see how a Select Committee of 14 people could bring the range of experience and wisdom to this Bill that I think it needs. I care about the NHS. If we have no other reason to be in this House, it is to defend the NHS. It is our duty to do that—without filibustering or playing games, but through several months of very, very hard and detailed work. My colleagues have already done much to make this Bill better. At the moment, I could not support it—there is much more work to be done. I, for one, ask for the opportunity to do my job.